Panic stations!

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THE DOCTOR SAYS
By Dr MILTON LUM

Sunday 5th June 2011
WE encounter stressful or dangerous situations at certain times in our lives, which generate feelings of anxiety and even panic.

However, panic disorders are different. The sufferer has recurrent and regular panic attacks that occur at any time, for no obvious reasons, on many occasions. Some sufferers experience an attack or two each month, while others can experience several attacks weekly.

Although the panic attacks do not usually cause physical harm or necessitate hospitalisation, they can be distressing for the sufferer as they can be intense, with the sufferer experiencing fear and terror.

Everyone who has a panic disorder experiences panic attacks. However, not everyone who experiences panic attacks has a panic disorder.

It has been estimated that about one in 10 persons experience an occasional panic attack.

Panic disorders are twice as common in women compared to men. They are more common in adolescents than in younger children.

How it comes about

The causes of panic disorders are not well understood. It is believed that they are due to a combination of physical and psychological factors.

Some people develop it after a traumatic incident, eg bereavement due to the loss of a loved one. This may occur soon after the incident, or even years later.

The risk of having a panic disorder is increased if a close family member has the condition. However, the nature of the risk is unknown.

It is believed that an imbalance of certain chemicals in the brain (neurotransmitters) can lead to an increase in the risk of developing the disorder. It is also believed that panic disorders may be due to the abnormal triggering of the body’s “fight or flight” reflex. This reflex is normally triggered when a person experiences a stressful or dangerous situation, which leads to the production of hormones that prepares the body to deal with the situation. The abnormal triggering of this reflex can lead to an exaggerated response, which results in a panic disorder.

Clinical features

The clinical features of panic disorders include a sudden onset of physical and psychological symptoms that can occur suddenly and unexpectedly for no apparent reason.

The physical symptoms are multiple, and include irregular heart beat (palpitations), dizziness, difficulty breathing, chest pain, a choking sensation, dry mouth, churning in the abdomen, excessive sweating, flushes, shivering, nausea, trembling, tingling sensations and numbness.

The psychological symptoms can be intense. There is anxiety, fear, terror, and even feelings of impending death.

The symptoms can lead to fears of the next attack, resulting in the creation of a vicious cycle of “fear of fear”. The concern about when the next attack will occur often leads to constant anxiety and worry.

The symptoms may be so intense that there may be feelings of disconnection from the situation, the surroundings and the body, as if the sufferer is an observer. This unreal sense of detachment, called depersonalisation, leads to confusion and disorientation.

There may also be occasions when the symptoms mimic a heart attack.

In general, the duration of most panic attacks is between five and 20 minutes, with the maximal intensity of the symptoms lasting no more than 10 minutes. However, reports of panic attacks that last longer are probably due to successive attacks.

Panic attacks in children are often dramatic, with increased breathing, screaming, and weeping. They can be particularly incapacitating, with severe attacks impacting upon the children’s development and learning. The fears may lead to poor concentration, cessation of schooling and/or involvement in social activities.

If untreated, panic disorders can affect one’s ability to drive and/or lead to the development of misuse or abuse of caffeine, alcohol and/or illicit drugs, eg marijuana, heroin, cocaine etc. It can also lead to other psychological conditions like phobias.

A consultation with a regular doctor will be helpful. It is essential that there is frankness and openness in the consultation. The doctor has to be provided information about the symptoms, the feelings associated with them, the situations in which they occur, and their effects on the patient. This facilitates correct diagnosis and prescription of appropriate treatment.

The doctor will carry out a physical examination to exclude other conditions that may be causing the symptoms, eg overactive thyroid. If there is difficulty in making a diagnosis, the doctor may carry out laboratory and/or imaging investigations, or refer the patient to a mental health team.

Management

The goals of management are to reduce the frequency and severity of the panic attacks. There are two modalities available – psychological therapy and medication. It is not uncommon for one modality to be prescribed initially, followed by another, or both prescribed together, depending on the patient’s response.

It is important that a patient understands what the treatment options involve and the possible risks or side effects. If there is anything that is unclear, the patient should seek clarification from the doctor.

Psychological therapy usually involves cognitive behavioural therapy (CBT), which is an effective therapy for panic disorders. This involves the patient having talking sessions with a therapist to identify reactions and feelings during panic attacks, as well as any negative beliefs and thoughts. This will enable the patient to develop more positive beliefs and thoughts, as well as exploring ways to cope with future attacks, eg breathing techniques.

There are guidelines on the frequency and duration of CBT, which the patient is advised to discuss with the therapist. Regular consultation with the doctor is necessary to assess the progress of treatment.

Medications used in the management of depression are also used to treat panic disorders, ie selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).

These medications can take two to four weeks before their effects are obvious.

The SSRIs and TCAs can only be taken under a doctor’s supervision. It is essential to keep the appointments with the doctor so that there is monitoring of progress. It is advisable to consult the doctor if there are troublesome side effects of the medications.

SSRIs increase the brain’s levels of serotonin, a compound which is thought to improve a person’s mood. They are as effective as the older TCAs, but have fewer side effects. The side effects of SSRIs, which include dry mouth, nausea, poor appetite, headaches, blurring of vision, sweating, feelings of agitation, inability to sleep and decreased sex drive, ease off with the passage of time.

Except for fluoxetine, SSRIs are not prescribed to children because there are reports of increased risk of self-harm and suicidal tendencies.

A low dose of SSRI is prescribed initially, and then gradually increased. There may be a temporary worsening of the feelings of anxiety and panic at the commencement of SSRIs, but the symptoms will return to normal levels within a few days in the majority of patients. If this does not occur, a consultation with the doctor is advised.

Sometimes, the doctor may carry out blood pressure measurements and regular blood tests for patients on SSRIs.

An alternative SSRI may be prescribed if there is no improvement after about three months of the initial medication.

The duration of treatment depends on a patient’s response. It is usual for the doctor to advise continuing taking the medication for at least six to 12 months after a successful response to the SSRI.

When a decision is made to cease taking SSRIs, the dose will be gradually reduced. Sudden cessation or the missing of a dose of SSRI may result in withdrawal symptoms like nausea, vomiting, headache, sweating, dizziness, numbness, tingling and sleep disturbances. These symptoms can be severe if there is sudden cessation of SSRI.

TCAs increase the brain’s levels of serotonin and noradrenaline, thereby improving a person’s mood. The side effects include dry mouth, blurred vision, constipation, problems passing urine, blurring of vision, drowsiness and sweating. These ease off after about 10 days. Cannabis should not be taken with TCAs as the heart rate can increase.

TCAs are usually prescribed if SSRIs do not help because they have more side effects than the SSRIs.

Beta-blockers are prescribed to control some anxiety symptoms like sweating and trembling.

They act by reducing the heart rate and the pumping force of the heart, thereby reducing blood pressure. The side effects include dizziness, cold hands and tiredness.

Beta-blockers are not usually prescribed in diabetics or asthmatics as they can worsen their symptoms. As they also interact with other medicines, a patient should check with the doctor or pharmacist prior to consuming other medicines in combination with beta-blockers.

As sudden cessation of beta-blockers can lead to side effects like an increase in blood pressure or a heart attack, prior consultation with the doctor is vital.

Sometimes, CBT or medications do not help in the management of a panic disorder. The attending doctor may have to refer the patient to a mental health team, which comprises psychiatrists, psychologists, etc, who will, after reassessing the problem, formulate a management plan for the individual patient.

Category: Milton's Corner
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